Failure to Follow Transfer Protocol Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions designed to prevent falls for a resident with a history of right hip and femur fractures. The resident was identified as a high fall risk and required a two-person transfer using a Hoyer lift, as documented in the care plan. Despite these interventions, a certified nursing assistant (CNA) attempted to transfer the resident from a wheelchair to bed without the required assistance and without using the Hoyer lift. During this transfer, the resident slid from the edge of the bed, twisted their ankle, and fell onto their right knee. As a result of the fall, the resident sustained a right distal femur fracture and required hospital evaluation. Facility records and staff interviews confirmed that the CNA did not follow the resident's care plan, which directly led to the accident and injury. The facility's investigation determined that the failure to adhere to the prescribed transfer protocol resulted in the resident's fall and subsequent fracture.